AUVELITY (dextromethorphan hydrobromide, bupropion hydrochloride)

Self-Administration – oral

Diagnosis considered for coverage:
  • Indicated for the treatment of major depressive disorder (MDD) in adults
Coverage Criteria:

For diagnosis of MDD:

  • Dose does not exceed one tablet twice daily; AND
  • Patient is 18 years of age or older; AND
  • Diagnosis of major depressive disorder (MDD); AND
  • Paid claims or submission of medical records (e.g., chart notes) confirming trial and failure to a minimum 30-day supply, contraindication, or intolerance to any TWO of the following generics:
    • bupropion 
    • citalopram 
    • desvenlafaxine succinate extended-release (ER) 
    • duloxetine 
    • escitalopram 
    • fluoxetine 
    • mirtazapine 
    • paroxetine 
    • paroxetine ER 
    • sertraline 
    • venlafaxine 
    • venlafaxine ER 
Reauthorization Criteria:

For diagnosis of MDD:

  • Dose does not exceed one tablet twice daily; AND
  • Documentation of a positive clinical response to therapy
Coverage Duration: 
  • Initial: 1 year
  • Reauthorization: 1 year
Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information: 
  • Starting dose: one tablet (45 mg dextromethorphan hydrobromide-105 mg bupropion hydrochloride) once daily in the morning
  • Maximum recommended dose: one tablet twice daily
  • The safety and effectiveness of Auvelity have not been established in pediatric patients
  • Contraindications:
    • With a seizure disorder
    • With a current or prior diagnosis of bulimia or anorexia nervosa as a higher incidence of seizures was observed in such patients treated with the immediate-release formulation of bupropion
    • Undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, and antiepileptic drugs
    • Taking, or within 14 days of stopping, MAOIs due to the risk of serious and possibly fatal drug interactions, including hypertensive crisis and serotonin syndrome
    • Starting Auvelity in a patient treated with reversible MAOIs such as linezolid or intravenous methylene blue is contraindicated
    • With known hypersensitivity to bupropion, dextromethorphan, or other components of Auvelity. Anaphylactoid/anaphylactic reactions and Stevens-Johnson syndrome have been reported with bupropion. Arthralgia, myalgia, fever with rash, and other serum sickness-like symptoms suggestive of delayed hypersensitivity have also been reported with bupropion 
Policy Updates:
  • 3/1/2023 – New policy approved by P&T
References:
  • Auvelity prescribing information. New York, NY. Axsome Therapeutics, Inc. October 2022. 

 

Last review date: March 1, 2023

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